ILLINOIS HEALTH CARE WORKER REGISTRY APPLICATION …
State of Illinois Department of Human Services Division of Developmental Disabilities
ILLINOIS HEALTH CARE WORKER REGISTRY APPLICATION FORM
(Please type or print legibly)
Applicant Information
Name:
Last
First
Date of Birth:
Social Security Number:
-
Month / Day / Year
Address:
Street Address / P.O. Box / Rural Route
Middle -
Apt.
City Telephone Number:
-
-
State Program Code:
Zip Code
Program Completion Date:
Month / Day / Year
Race
Optional Information
Asian / Pacific Islander
American Indian / Alaskan Native
White
Black
Unknown
Sex
Male
Female
Eye Color
Blue Hazel
Green
Brown
Height
(feet)
(inches)
Consent to Place Information on Registry
Your signature on this application certifies that the information provided is accurate and grants permission to the State of Illinois and any affiliate acting on the behalf of the State of Illinois to place information from this form on the Illinois Care Worker Registry.
Signature
IL462-1292 (N-6-12) Illinois Health Care Worker Registry Application Form Printed by Authority of the State of Illinois 0 Copies
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